RWJF Scholars Work to Strengthen Rural Nursing

From Alaska to Kentucky to Wyoming, Robert Wood Johnson Scholars and grantees spearhead projects to improve access to high quality nursing care in remote areas.

What do Crawford, Colo. and Chokio, Minn. have in common? They are both remote U.S. communities that now have access to a precious commodity: local health care.

That's thanks to the presence of midwives and nurse practitioners who recently graduated from Frontier Nursing University, a graduate program that offers distance education to nurses with an interest in nurse-midwifery and family nurse practitioner and women’s health specialties. Located in the small town of Hyden, Ky., the university aims to build a pipeline of highly educated nurses serving in rural or underserved areas.

“We’re trying to introduce primary care providers into rural areas in such a way that they can provide high quality care and preventive services too,” says Suzan Ulrich, DrPH, CNM, FACNM, associate dean of midwifery and women’s health at Frontier Nursing University and a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow (2012-2014).

Ulrich is one of a number of RWJF scholars working to increase access to health care—and improve its quality—in underserved and hard-to-reach rural areas. As chair of Frontier Nursing University’s admissions committee, she tripled the size of its student body between 2005 and 2011. The school is on course to grow further; in January, it received a $1.35 million grant from the federal government to provide scholarships to 90 students over four years.

Graduates often go on to become the only certified nurse-midwives or primary health care providers in their communities, Ulrich says, pointing to women like Jenny Mitchell, FNP, who started the first and only health care clinic in Crawford, Colo., and Paige McNally, RN, CNM, the first and only midwife in her community in Chokio, Minn. “As I recall, Paige can hardly go to the grocery without seeing someone whose birth she attended,” Ulrich says.

Rural Areas Face Unique Challenges

Demand for health care is rising nationwide thanks to an aging population that is living longer, and sicker, with multiple chronic conditions. The need for health care providers will intensify next year, when millions of new patients will become eligible for health insurance under the health reform law passed in 2010.

But rural parts of the country face unique challenges, according to Alan Morgan, BS, MPA, CEO of the National Rural Health Association. Shortages of health providers, including nurses, can be particularly acute in rural areas, he said. And these nurses and other providers have less access to education programs, which tend to be located in more densely populated areas. Programs that offer advanced degrees, from the baccalaureate to the doctorate, can be especially difficult to access for students living in rural areas.

One solution is to be more proactive in identifying and educating nurses from rural areas, Morgan said. That is a key goal of Frontier Nursing University, which offers distance education programs that enable students to remain in their home communities and a “bridge” program that allows nurses with associate’s degrees to move more easily into master’s and doctorate programs. “These students really love where they live,” Ulrich said. “If we can educate them to stay within their communities, then those communities are going to have a provider who’s going to be there a long time.”

Educating rural nurses is the mission of other RWJF-supported programs, including one in Bethel, Alaska, a remote village in the far reaches of the western part of the state that is 350 miles from Anchorage and accessible only by water and air.

The project—supported by Partners Investing in Nursing’s Future (PIN), a partnership of RWJF and the Northwest Health Foundation—aims to increase the number of Alaska Natives educated in nursing and to develop a statewide training model to ensure that hospital nurses are held to a standard set of competencies.

The goal is to alleviate problems related to a shortage of registered nurses in the state and a high nursing turnover rate, which results in a forced reliance on traveling nurses from other states. Many traveling nurses lack an understanding of Native cultures and the unique health issues in remote areas. To address those concerns, the PIN project trained aspiring Alaska Native nurses in Bethel, more than doubling the number of nurses who speak Yup’ik, the language of the local tribal nations, and diversifying the local nursing workforce. “That’s a big deal,” said Mary Elizabeth Rider, MSW, a consultant who worked on the project.

Nurse educators also developed common rural nursing competencies that are now in use at a number of hospitals in Alaska. The shared competencies help ensure that nurses in the state’s hospitals can meet health needs in remote, underserved areas. “To be a good rural generalist, you have to be qualified to do everything well,” Rider said. “We needed to make that happen.”

Aiming to Revolutionize Nursing Education

Nurse leaders in Wyoming, meanwhile, have spearheaded a PIN project to expand opportunities for nurses to develop leadership skills so they can play a more influential role in the state’s health care system. Many nurses have not progressed in their education beyond their associates’ degrees, which can make it difficult for them to achieve high-ranking positions, said Mary Burman, PhD, RN, dean and professor at the school of nursing at the University of Wyoming and an ENF alumna (2007-2009). “The need to work and develop all of us in nursing is really critical.”

The Wyoming PIN project is also working to create a shared nursing curriculum at academic institutions across the state to make it easier for nurses prepared at the associates-degree level to earn baccalaureate and higher degrees. Streamlining education requirements is especially helpful in a state like Wyoming, which is home to only one four-year school of nursing. When the process is complete, nurses at one of the state’s six community colleges will have an easier time earning their baccalaureate degree at the University of Wyoming, which will help them build the skills they need to care for an increasing, and increasingly complex, population of patients.

“Our goal is to revolutionize nursing education,” Burman said. “We see that, as you look at the future of nursing, we need a different type of nurse clinician.”

A third PIN project in eastern North Carolina, Partners for Rural Nursing, took a different approach. It created and activated local nursing councils in rural communities to devise and implement strategies to recruit and retain nurses. The effort mobilized nurse leaders with varying expertise, including work in hospitals, public health, long-term care, school nursing, community college nursing education, mental health, hospice, home health and military health.

The National Rural Health Association’s Morgan applauds efforts like these to build the nursing workforce in rural areas. “There is no path forward without a fully functioning nurse workforce, one that we invest in and one where nurses are allowed to practice to the fullest extent of their education,” he said. “Taking a look forward, and knowing the workforce needs of the future, we’ve just got to put a stronger emphasis on the nursing profession than we have been.”